Ellen Hayden knows the trauma of breast cancer. The single mother from Hampton lost her mother at the age of 7. Her mother died at the age of 56, seven years after originally being diagnosed with breast cancer and later undergoing a radical mastectomy surgical procedure.

Michael McCord

Ellen Hayden knows the trauma of breast cancer. The single mother from Hampton lost her mother at the age of 7. Her mother died at the age of 56, seven years after originally being diagnosed with breast cancer and later undergoing a radical mastectomy surgical procedure.

Recent controversial recommendations of fewer and later mammograms did not please Hayden.

The United States Preventive Services Task Force last week recommended against routine screening mammography in women under age 50 and said its recommendations were based on clinical evidence. But Hayden, like many Americans upset by the new guidelines, said she thinks it was more about economics than health.

"I'm not sure what to make of it. It seems like more lobbying and stuff from the health insurance industry so they can save money," said Hayden, who works two jobs to make ends meet. "If my mother had early screening, she might have lived. Why not do it early if it will save lives?" If Hayden, 44, seems skeptical about the health insurance industry it's because she is battling her insurance provider over payment for a doctor-recommended MRI that came after an abnormal reading from an annual mammogram. For Hayden, and many other Americans, it's a simple case of "an insurance company getting between me and my doctor" and an example why health care reform is needed.

"When will our doctors be able to diagnose their patients in the best manner they see fit without having the interference of insurance companies?" Hayden wrote in a letter to the editor. "They don't care about people, only profits."

Hayden works as an industrial supply salesperson for an Illinois company and gets her health insurance through Blue Cross and Blue Shield of Illinois. The insurer said the MRI denial was not about money but rather a matter of her policy, which requires Hayden to get preapproval for certain procedures such as the MRI. The insurer said it also was a matter of employing what they consider to be best medical practices, such as a biopsy or ultrasound before proceeding to an MRI.

Mary Ann Schultz, a spokesperson for Blue Cross and Blue Shield of Illinois, said their "main role is to make sure members have access to appropriate care, based on evidenced-based medical guidelines and other sources of information, which are the basis of our medical policies."

The insurer is not paying for the MRI, which is a more expensive procedure, and Hayden says the insurer won't pay for second one despite a doctor's recommendation for at least one follow-up MRI.

Hayden said she can't afford to pay for the first one and can't even think about paying a second one from her own pocket. (Because of the recession, Hayden said she may also lose her health insurance coverage at the beginning of the year if her sales quota isn't reached.)

"These insurance companies need to be held liable for preventing doctors from using the best possible tools for early detection," Hayden said. "If they stop it and a woman ends up with cancer, they should be held responsible. Someone has to stop them."

Hayden's story and frustration is a microcosm of hundreds of thousands of ongoing health insurance coverage disputes and represents the high expectations of the premium-paying public clashing with limitations of the insurer. What the insurer calls "appropriate care, based on evidenced-based medical guidelines" might be considered inadequate by patients concerned about their health.

"It's understandable that this is an emotional issue because most patients believe that 'nothing is going to stand between me and what I want to get done,' " said Ned Helms, a former health insurance industry executive and director of the N.H. Institute of Health Policy and Practice at the University of New Hampshire.

Helms was not speaking about the specifics of Hayden's case but about the larger complexities of a health care system that is little understood by most Americans — especially about the amount of rationing and limitations on coverage that already take place in a country health care system that spends $2 trillion and 16 percent of the gross domestic product on health care.

"Because there's inconsistency between insurers, each of us could pick out some sort of incident that has happened with an insurance company and most of us would agree that it's awful," Helms said. "The question always is, is that the exception to the rule or does it happen all the time?"

Hayden's case began more than a year ago with the abnormal mammogram reading. An MRI was recommended in a joint consultation with her doctor and radiology specialist (Hayden's doctor declined requests to be interviewed for this story) and it was set up and taken at Portsmouth Regional Hospital.

Hayden, who began taking regular mammograms in her early 30s, in part because of her mother's breast cancer, did not know her policy required preapproval and assumed it was all right because her primary care physician's office had set it up.

"The MRI reading was OK and another was recommended in six months just to make sure," Hayden said.

She hit her first roadblock when her insurer refused first to pay for the MRI reading and then later said it would not pay for the MRI itself after Hayden received a bill from the hospital.

Seacoast Sunday gained permission from Hayden to talk about the case with Blue Cross and Blue Shield of Illinois. Schultz said that a four-doctor panel reviewed the case for this story and confirmed its original decision. She said Hayden and her physician can appeal the decision, which they have not done.

"The appeal process is in place to provide a fair and unbiased process for instances like this one," said Schultz. "As part of the appeal process, we use an independent, external reviewer — in cases like this, a surgeon or oncologist. The reviewer has the option to maintain or reverse the decision, citing BCBSIL medical policy or based on clinic grounds, practice guidelines, or other sources of information."

Hayden said she plans to appeal.

"We have this notion in our political debate and popular culture that we can't have reform because that means that government bureaucrats will make decisions but we already have insurance people playing that role," said Helms, who believes that for the most part insurers use proper medical rationales in their decisions. For the long term, Helms said, for reform to properly work, there needs to be accountability across the board — for medical providers, insurers, who often "write their own rules for the road," and patients who are shielded from the true costs of medicine.

"When it's about health and money, people get agitated," Helms said. "There will always be individual instances where people will be unhappy, but that's part of the human drama."

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